6

Principles of Therapeutic Change

in Treating Depression with an Integrative
Application of the Cognitive Behavioral
Analysis System of Psychotherapy
Dina Vivian

My Reaction to the List of Principles and Tasks That I Have

to Accomplish

As a mentee of Marvin Goldfried, I “grew up” viewing psychological treatment

through a “principles of therapeutic change” lens. However, in reviewing the
empirically based list of principles provided by the editors (and those listed in
Castonguay & Beutler, 2006), I realized that the process by which these princi-
ples guide my clinical work has become, in part, implicit and automatic. As will
become evident in this chapter, I also find that many of the principles build on
each other in treatment planning/delivery and are not as distinct within and
across categories as the authors present them. On the contrary, they are highly
interconnected and operate via a multifaceted, iterative, and dynamic process.
Nevertheless, classifying them into unique, yet interrelated, categories is likely
to provide a helpful heuristic for a systematic evaluation of how they affect
treatment.
While compelling, the experience of reviewing the long list of principles and
attempting to articulate how each principle may affect treatment for each of the
three patients herein has brought to focus the complexity of, and challenges
inherent in, delivering efficacious patient-centered treatment. In fact, due to
the ideographic interplay of the mechanisms maintaining each patient’s psy-
chopathology, the task of identifying which principles are likely to play the most
prominent role in each patient’s treatment, when their role may be critical, and
adapting treatment accordingly is arduous. Additionally, I suspect that because
of the often unpredictable nature of in-session events, this process may re-
main, at times, elusively implicit. Nevertheless, I agreed to write this chapter in
 PrINCIples oF THERA pe UTIC CHANge 130

hopes that it would help me articulate how I apply the principles with the three
patients, identify which principles most guide my work, and derive guidelines
for how to translate this process into training.
Although I think clinically in terms of principles of change, my work is
broadly framed within cognitive-behavioral therapy (CBT) approaches.
Moreover, for the past two decades, it has been guided by the Cognitive-
Behavioral Analysis System of Psychotherapy (CBASP), an integrative treat-
ment based on contemporary learning theories that was specifically designed
to address the entrenched interpersonal problems associated with chronic/
complex depression (McCullough, 2000, 2006). Based on substantial re-
search on chronic mood disorders, a main assumption in CBASP is that the
impact of (malevolent) significant others plays a pivotal role in shaping de-
pressive patients’ maladaptive interpersonal need expectancies and dysfunc-
tional self-perception. Relatedly, the ensuing lack of “perceived functionality,”
namely, the awareness of the role they play in affecting their own dysfunctional
outcomes, is seen as maintaining low self-efficacy, external locus of control,
and helplessness. The interplay of these factors, in addition to chronic negative
affectivity and skills deficits, leads to a dysfunctional interpersonal approach
characterized by disconnection from others and inability to recognize and/or
benefit from positive regard. The associated paucity of positive connections
with the interpersonal environment and/or social isolation fuels and maintains
the mood problems.
As a result, the main goals for treatment include increasing patients’
perceived functionality and fostering their (positive) connection with the en-
vironment and others. To this end, the situational analysis, a primary CBASP
intervention, guides patients to (a) unpack their most distressing interper-
sonal and intrapersonal events in the here and now, (b) identify mismatches
between actual outcomes and desired outcomes, and (c) become aware of the
dysfunctional cognitive-behavioral patterns that preclude them from getting
their needs met. In other words, cognitive-behavioral changes are al- ways
linked to their function (i.e., attaining a desired outcome). An additional
therapeutic mainstay of CBASP, referred to as disciplined personal involve-
ment (DPI), involves the planful and pinpointed use of the therapist–patient
relationship as a vehicle of change. Specific DPI interventions, the interper-
sonal discrimination exercise (IDE) and the contingent personal responsivity
(CPR), are designed to foster emotionally mediated change by increasingthe
patient’s awareness of maladaptive transference patterns and therapy
inhibiting behaviors, as well as by promoting in-session corrective inter-
personal experiences to address the long-lasting impact of early adversity.
Lastly, interventions from other CBT models, such as behavioral activation,
behavioral rehearsal, and skills training (e.g., assertiveness, effective commu- nication, stress
management, emotion regulation/tolerance, sleep hygiene) can also be integrated into CBASP in a
patient-centered and ideographic way to foster response.